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Falls among older people present General Practitioners and other health professionals with both a challenge and an opportunity.
As the likelihood of falling increases with age, do we respond by saying falls are inevitable? Or do we look at putting
in place individualised interventions that reduce the risk of an older person falling?
Falls in older people are often categorised as accidents caused by identified hazards in the environment. However, the
real cause of a fall is the interaction between the hazard and the person’s age-related changes in functioning and disease
Both parts of this interaction can be addressed to prevent falls: removing hazards in the home or community environment,
and better management of the person’s age-related impairment or condition. This is an important role for primary care
clinicians, who have a broad understanding of the health status and living situation for most people enrolled with their
The “Reducing Harm from Falls” national programme, led by the Health Quality & Safety Commission
(HQSC) in partnership with ACC and other key agencies, supports health professionals in managing older people’s wellbeing.
The programme aims to prevent falls and reduce harm related to falls (such as skin tears, fractures, head injuries or
loss of confidence and independence).
Reducing the harm caused by falls has been the first focus area of the national patient safety campaign, “Open
for better care”. The campaign is co-ordinated nationally by the HQSC and implemented locally by DHBs and other
healthcare providers. In the Northern Region, “Open for better care” is partnered with the “First, Do No Harm” patient
“10 Topics on reducing harm from falls” is a set of learning activities offering up-to-date and evidence-based
information for anyone involved in the care of older people at risk of falling. Links to articles published in Best Practice
Journal are given in topics on hip fracture prevention and care (Topic 6), prescribing vitamin D (Topic 7), and medicine
use in relation to falls risks (Topic 8).
Why assess falls risk?
One-third of people aged over 65 years living in the community have at least one fall a year, and the rate of falls
increases with age.1 Asking patients about falls is important because falls are the leading risk factor for
injury in older age,2 with fractures and head injuries the most serious injuries.
Hip fracture can be life-changing for older people and their families. Between 10 – 20% of older people will be admitted
to residential care as a result of hip fracture; 27% will die within a year, and, of these people, almost two-thirds would
not have died had they not fractured their hip.3, 4, 5
Even if older people are not physically injured in a fall, fear of further falls may cause them to unnecessarily restrict
their physical and social activities, often reducing their fitness and quality of life.1
Older people living in the community tend to be unrealistically optimistic about falls, with most believing falls are
a potential problem for their age group, but only a minority believing this risk applies to them.6
Current clinical guidelines on preventing falls in older people recommend routinely asking older patients if they have
had a fall in the past year; many older people who have a fall do not talk about it.7, 8
The “Ask, assess, act” project is a key initiative in the national falls programme. A few simple screening
questions can help identify which patients to target for in-depth, individualised, multi-factorial assessment and interventions.
The “ask” element suggests asking older patients the following questions:
- Have you slipped, tripped or fallen in the last year?
- Can you get out of a chair without using your hands?
- Have you avoided some activities because you are afraid you might lose your balance?
- Do you worry about falling?
The “assess” element recommends talking with patients and their families/whānau and caregivers to identify risk factors
for falls. Clinical assessment covers known risk factors for falls, including muscle weakness, impaired balance, limited
mobility, postural hypotension and impaired gait, vision or cognition. Other falls risk factors include the use of psychoactive
medicines or multiple medicines, depression, dizziness, arthritis, diabetes mellitus, pain and urinary incontinence.9 Osteoporosis
or anticoagulant treatment increases the likelihood of harm from a fall.
The “act” element is the most critical - determining what support and interventions might be helpful, and taking specific
actions to address the older person’s particular risk factors. Many interventions that reduce falls risk are likely to
be part of routine care of older people, such as managing medicines and addressing foot problems. A plan of action based
on the older person’s priorities and preferences is more likely to be considered manageable by family/whānau and caregivers
The suite of resources for the “Ask, assess, act” project, including a pocket
card, can be downloaded from the Reducing Harm from Falls webpage: www.hqsc.govt.nz/our-programmes/reducing-harm-from-falls/projects/ask-assess-act/
Topic 2: Which older person is at risk of falling? (from “10
Topics on reducing harm from falls”) provides background on the “Ask, assess, act” project in more detail, and can be
found at: www.hqsc.govt.nz/our-programmes/reducing-harm-from-falls/10-topics/topic-2/
Basic home safety is an important consideration for all older people. A helpful check-list, “How safe is your home”,
is available from the ACC website (ACC home safety checklist 5218, www.acc.co.nz).
Referral to an occupational therapist for environmental safety assessment and modifications reduces falls in home settings
for individuals identified as having a high risk of falling.10
Older people tend to view falls as a threat to their independence and sense of identity. In one study of older people’s
views, 80% of participants said they would rather be dead than be admitted to a rest home after a serious hip fracture.11 It
is important to try to keep conversations about falls positive, focusing on preserving independence and restoring their
previous level of activity.
Ideally, identification and management of falls risk should be embedded in personal health assessment protocols within
primary care; the Reducing Harm from Falls programme team is currently exploring how this might be achieved.
The role of vitamin D in reducing falls
Current international falls prevention guidelines recommend vitamin D supplements to reduce falls in older people, particularly
those at higher risk of falling.7, 8 Vitamin D deficiency may cause muscular impairment even before there
are adverse effects on bones,12 which increases the risk of falling. Low levels of vitamin D have been associated
with reduced bone mineral density, high bone turnover and increased risk of hip fracture.
Vitamin D supplements may be prescribed without a blood test for older people who are likely to have a vitamin D deficiency,
e.g. those who are housebound, require home support services, live in age-related care facilities, are frail or dark-skinned.13,
A Cochrane review of falls prevention interventions in older people living in the community found that vitamin D supplements
did not reduce falls overall, although there was a 30% reduction in falls risk in the subgroup of trials that recruited
only people with lower vitamin D levels.10 Residents in age-related care facilities who take vitamin D supplements
have 37% fewer falls than those not taking a supplement.15
ACC information sheets providing vitamin D prescribing advice for general practice
teams and pharmacists can be found at: www.acc.co.nz/preventing-injuries/at-home/older-people/information-for-older-people/PI00014
The evidence base on the role of vitamin D in reducing falls and fractures is
complex and evolving as clinical trials come to completion, such as the Auckland-based Vitamin D Assessment (ViDA) study.
A brief discussion of current evidence is presented in Topic 7: Vitamins D and falls: what you need to know, which can
be found at: www.hqsc.govt.nz/our-programmes/reducing-harm-from-falls/10-topics/topic-7/
Improving balance and strength
Certain exercise programmes have been found to be effective in reducing falls and fall-related injuries in older people
living in the community. These interventions can also reduce health system costs by decreasing fall-related hospital admissions
among older people living in the community by up to 10%.
Both group and home-based multiple-component exercise programmes have been shown to reduce falls by approximately 30%,10 and
it is likely that there is better value for money and more benefit among people at higher risk, e.g. those who have had
a fall in the past year. Attendance at Tai chi classes has been shown to reduce falls by 28%, although classes are more
effective for participants who are not at high risk of falling.10
Older people may be reluctant to participate in exercise programmes for reasons such as fatalism, fear of falling, no
previous history of exercise, poor health and functional ability, low health expectations and the stigma associated with
programmes targeting older people.16
As many older people do not consider themselves at risk of falling, it is important to promote exercise classes by emphasising
their positive benefits for health, wellbeing and independence.17
Many older people enjoy the social aspect of group classes, but home-based programmes are also valuable because some
people dislike joining groups or find them difficult to attend. Older people are more likely to participate if they are
encouraged by a health professional and are offered a choice of programme types and settings.
To match patients with exercise programmes, contact local Green Prescription coordinators
or ACC community injury prevention consultants at: email@example.com
Topic 9: Improving balance and strength to prevent falls, discusses
the effectiveness of exercise programmes designed to prevent falls, including a summary of the evidence on effective components,
exercise ‘dose’ and duration. It can be found at: www.hqsc.govt.nz/our-programmes/reducing-harm-from-falls/10-topics/topic-9/
Falls are everybody’s business
A key message of the falls focus of the “Open for better care” campaign is that falls are everybody’s business. Taking
action to reduce the harm caused by falls is an important part of helping older people to maintain their health, wellbeing
and quality of life.
Falls prevention efforts aim to see falls risk identification protocols and falls prevention programmes increasingly
in place across all care settings, particularly primary care, and a corresponding reduction in falls-related hospital
and ED admissions.
For further information on falls, see: www.hqsc.govt.nz/our-programmes/reducing-harm-from-falls/
For further information on the Open for better care national patient safety campaign,
- Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing 2006;35(s2):ii37-ii41.
- Ministry of Health. Health loss in New Zealand: A report from the New Zealand burden of diseases, injuries and risk
factors study, 2006–2016. Ministry of Health, Wellington, 2013.
- Autier P, Haentjens P, Bentin J, et al. Costs induced by hip fractures: a prospective controlled study in Belgium.
Belgian Hip Fracture Study Group. Osteoporos Int 2000;11(5):373–80.
- Kiebzak GM, Beinart GA, Perser K et al. Undertreatment of osteoporosis in men with hip fracture. Arch Intern Med
- New Zealand Health Information Service. Fractured neck of femur services in New Zealand hospitals 1999–2000. Ministry
of Health, Wellington, 2002.
- Dollard J, Barton C, Newbury J, Turnbull D. Older community-dwelling people’s comparative optimism about falling:
A population-based telephone survey. Australas J Ageing 2012;32(1):34-40.
- Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary
of the updated AGS/BGS clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011;59:148–57.
- National Institute for Health and Care Excellence. NICE Clinical guideline 161 Falls: assessment and prevention
of falls in older people, 2013. Available from: http://publications.nice.org.uk/falls-assessment-and-prevention-of-falls-in-older-people-cg161 (Accessed
- Delbaere K, Close JC, Heim J, et al. A multifactorial approach to understanding fall risk in older people. J Am
Geriatr Soc 2010;58(9):1679-1685.
- Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the
community. Cochrane Database Syst Rev 2012;(9):CD007146.
- Salkeld G, Cameron ID, Cumming RG, et al. Quality of life related to fear of falling and hip fracture in older women:
a time trade off study. BMJ 2000;320(7231):341–6.
- Glerup H, Mikkelsen K, Poulsen L, et al. Hypovitaminosis D myopathy without biochemical signs of osteomalacic bone
involvement. Calcif Tissue Int 2000;66(6):419–24.
- Ministry of Health and Cancer Society of New Zealand. Consensus statement on vitamin D and sun exposure in New Zealand.
Ministry of Health, Wellington, 2012.
- bpacnz. Vitamin D supplementation: navigating the debate. BPJ 2011;36:26–35.
- Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older people in care facilities
and hospitals. Cochrane Database Syst Rev 2012;(12):CD005465.
- Bunn F, Dickinson A, Barnett-Page E, et al. A systematic review of older people’s perceptions of facilitators and
barriers to participation in falls-prevention interventions. Ageing Soc 2008;28:449–72.
- Yardley L, Bishop FL, Beyer N et al. Older people’s views of falls-prevention interventions in six European countries.